ethics abandoned - medical professionalism and detainee abuse in the war on terror

8/13/2019 Ethics Abandoned - Medical Professionalism and Detainee Abuse in the War on Terror

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Finding 3. The DoD and CIA required physicians, psychologists, and other health profes-

sionals to act contrary to their professional obligations. These obligations include refraining

from harming individuals with whom they interact in their professional capacities, main-

taining confidences, being transparent about their professional roles, and exercising inde-

pendent professional judgment. The agencies inappropriately held health professionals to

ethical standards contrary to professional ethical principles. They also equated compliance

with professional ethical standards with conformance to the far lower standards of crimi-

nal law; excused violations of ethical standards by inappropriately characterizing health

professionals engaged in interrogation as safety officers; implemented rules that under-

mined the ethical requirement of confidentiality for detainee medical information; required

physicians and nurses to forego proper medical judgment to force-feed competent

detainees engaged in hunger strikes; and improperly designated licensed health profes-

sionals using professional skills in interrogation as combatants, a status incompatible with

their licensing.

Since 2006, the DoD has enacted reforms promoting professionalism in the clinical

treatment of prisoners, and it recently instituted a medical advisory committee to review

ethics concerns in the treatment of prisoners at Guantnamo, but it continues to uphold

policies that undermine standards of professional conduct in the context of interrogation,response to hunger strikes, and reporting abuse.

Recommendation: The DoD and CIA should ensure that health professionals in

detention centers adhere to the ethical principles of their professions.

The DoD and CIA should adopt standards of conduct for health professionals

involved in detainee interaction that conform to those standards of conduct

established by the health professions. These standards include the basic

duties of all professionals who employ their professional skills, regardless of

role, to avoid harm, to uphold transparency and honesty, to protect

confidentiality, and to respect detainee autonomy in responding to hunger

strikes. The agencies should affirm the duties of health professionals to

report coercive and abusive practices to authorities; refrain from conducting,

being present during, monitoring, or otherwise participating in

interrogations, including developing or evaluating individual interrogation

strategies; and refrain from providing medical information to interrogators

or advising on conditions of confinement that advance interrogation.

The DoD should no longer classify military health professionals who use

their professional skills in their job as combatants. It should rescind all

guidelines, instructions, and other policies that explicitly or implicitly state

the contrary.

F>> > '==>> K

The investigation should include substantive interviews with and medical

examinations of detainees released from or still in U.S. custody, subject to

their consent. The interviews should include guarantees of no reprisal.

Where supported by the investigations findings, the report should include

an acknowledgment of acts of torture or cruel, inhuman, or degrading

treatment committed against detainees in U.S. custody, and the damage

done to their health, families, and social relationships.

The investigation should review all relevant CIA and military records,

including detainee medical records and interrogation logs.

The president should declassify as much information contained in the

investigations report as possible, except when there are compelling

national security reasons for retaining classification. This should include

removal of redactions in previously released documents under the same

standard.

Finding 2. The president has issued an executive order prohibiting the use of torture and

other forms of cruel, inhuman, or degrading treatment, and has repudiated Justice

Department legal memoranda authorizing its use. However, the Army Field Manual on

Human Intelligence Collector Operations, which binds both military and CIA interrogators,

permits methods of interrogation that are recognized under international law as forms of

torture or cruel, inhuman, or degrading treatment. Such methods include sleep depriva-

tion, isolation, and exploitation of fear.

Recommendation: The United States should end authorization of the use of

interrogation methods that amount to torture or cruel, inhuman, or degrading

treatment or punishment.

The president should issue an executive order specifically prohibiting the useof sleep deprivation, isolation, exploitation of fear, and other interrogation

methods that violate international standards regarding torture and other

forms of cruel, inhuman, and degrading treatment. The Department of

Defense (DoD) should revise its Army Field Manual on Human Intelligence

Collector Operations in accordance with the new executive order.

The United States should accede to the Optional Protocol to the Convention

Against Torture, which requires the creation of an independent domestic

monitoring body for the purpose of preventing torture against individuals

in custody.

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their independent medical judgment in assessing detainee competence to

make decisions;

maintenance of confidentiality between detainees and physicians;

provision of advice to detainees that is consistent with professional ethics

and standards;

prohibition of force-feeding and the use of physical restraints;

access to independent medical advice when detainees request it;

training of health professionals deployed to detention facilities in the

ethical management of hunger strikes in accordance with the Declaration

of Malta;

institution of informed refusal and advance directives so that detainees can

express their intent regarding feeding;

development of policies and protocols for alternative means of resolving

detainee grievances.

The DoD should rescind all policies, protocols, and instructions to the contrary.

Finding 5. The military system of quality assurance, credential review, and discipline of

military health professionals fails to ensure that health professionals who engage in abuse

of individuals in custody or do not provide competent treatment to abused detainees are

held accountable for their acts.

Recommendation: The DoD quality assurance system, including the Medical

Quality Assurance program and Clinical Quality Management in the Military

Health System, should include measures of compliance with professional

standards of detainee treatment. These measures should include adequacy

and appropriateness of clinical diagnosis, treatment, and documentation;

confidentiality of information; and refraining from abuse as well as reporting

abuse of detainees. Measures of compliance should be revised periodically

to reflect changes in ethical principles established by the health professional

associations. Violations should be reported to the National Practitioner Data

Bank, the Federation of State Medical Boards, and the Association of State

and Provincial Psychology Boards, which should share relevant information

with state licensing boards, specialty certification boards, and medical associa-

tions for appropriate action.

F>> > '==>> K

The DoD and CIA should prohibit the use of information obtained from

medical or psychological treatment or assessments from being shared

directly or indirectly with military or intelligence agency interrogators or

used in interrogation. The agencies should rescind all guidelines, instruc-

tions, and other policies that explicitly or implicitly state the contrary.

Consistent with international and domestic ethical standards, medical

examinations to determine whether an individual should not be interro-

gated or to treat conditions that arise during interrogation would not be

affected by this standard.

To ensure reporting abuse by health professionals, the DoD and CIA should

establish mechanisms for investigating and reporting abuse that are

consistent with international standards.

Finding 4. In responding to hunger strikes by detainees, the DoD has failed to adhere

to the requirements of the World Medical Associations Declaration of Malta, which

calls upon physicians to evaluate, support, counsel, and meet the needs of the com-

petent and voluntary hunger striker, including respecting the strikers refusal to eat.

The American Medical Association has also taken a strong position against forced

feeding of hunger strikers. The DoD has engaged physicians and nurses in the force-

feeding of hunger strikers in violation of professional ethical standards. It has also

engaged them in using physical restraints in the process of force-feeding, which

depending on individual circumstances amounts to either torture or inhuman and

degrading treatment. In some cases force-feeding with the use of physical restraints

has lasted for months at a time and in a few cases for years. The decision to force-feed

is a command decision, thereby preventing physician independence and autonomy. In

many cases, officials began force-feedings before the detainee was at any health risk

from not eating. The process of force-feeding requires nurses to act in a manner that

precludes their using independent judgment and responding to the needs of thedetainee subjected to force-feeding.

Recommendation: The DoD should establish policies, procedures, and standards

of care that are in keeping with established professional ethical standards

regarding detainees engaged in hunger strikes.

The DoDs guidelines for hunger strikes should include:

explicit affirmation that health professionals who evaluate and advise

detainees engaged in hunger strikes should follow the standards of the

World Medical Associations Declaration of Malta, including the use of

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standards regarding participation in interrogation that follow the standards

adopted by medical associations.

Finding 7. Licensure by a state agency or board is a condition of employment for military

physicians and psychologists, and should be a requirement for intelligence agency physi-

cians and psychologists as well. State agencies retain the authority and responsibility to dis-

cipline licensed health professionals who have engaged in professional misconduct, which

under the laws governing professional conduct applies to abuse of detainees. Licensing

and disciplinary boards have dismissed all cases brought against health professionals for

involvement in detainee abuse, most on procedural grounds or by substantive decisions

inconsistent with the obligations of health professionals as required by law.

Recommendation: Through legislation and other appropriate mechanisms, states

should make explicit that supporting interrogation and participating in torture

or cruel, inhuman, or degrading treatment are forms of sanctionable misconduct

by licensed health professionals. State licensing boards, as appropriate under

state law, should establish adequate procedures for fair investigation and adjudi-cation of complaints about abuse of prisoners and detainees. Congress should

support the ability of states to discipline members of U.S. military and intelli-

gence agencies who engage in prisoner abuse.

State law should provide the following:

Professional misconduct includes (a) participation or complicity in torture

and other forms of cruel, inhuman, or degrading treatment of a prisoner;

(b) violations of professional norms in connection with interrogation,

including any form of participation in, or sharing of medical information

regarding, an interrogation; and (c) use of professional expertise to advise

on a prisoners conditions of confinement in a manner that impairs the

well-being of the prisoner.

Health professionals have a duty to report incidents of suspected torture

or abuse of prisoners to the appropriate authorities and failure to do so

constitutes misconduct. Individuals who provide good-faith reports of torture

or abuse to state disciplinary boards will be protected from reprisals.

Disciplinary boards have jurisdiction to investigate and prosecute licensees

for misconduct regardless of the location, timing, or circumstances of the

misconduct. Disciplinary boards must (a) investigate non-frivolous complaints

of prisoner abuse, (b) prima facie charge the licensee when it finds probable

cause of a violation, (c) articulate specific reasons for dismissal of a complaint

F>> > '==>> K

Finding 6. In response to the revelation of health professional participation in detainee

abuse, medical associations have properly clarified ethical standards to affirm that physi-

cians should not participate in interrogation or any practices related to interrogation, tor-

ture, or abuse. In addition, the American Medical Association has affirmed the World

Medical Associations stance that physicians should not force-feed hunger strikers.

However, additional clarification and elaboration of standards is necessary, as are proactive

steps to ensure the United States adherence to ethical standards regarding interrogation

and conditions of detention, treatment of detainees, and proper medical management of

hunger strikers, including prohibitions of force-feeding. The American Psychological

Association, while reaffirming its opposition to torture, has inappropriately continued to

affirm the propriety of psychologists participating in interrogation.

Recommendation: Professional medical associations and the American

Psychological Association should strengthen their ethical standards regarding

interrogation and detention of detainees and take proactive steps to foster

compliance with those standards.

The American Medical Association, American College of Physicians, and the

American Psychological Association should: develop, distribute, and promote further refinements in ethical principles

regarding interaction with prisoners and detainees, including roles in

interrogation, conditions of confinement, abuse reporting, confidentiality

of detainee medical records, and treatment of detainees including hunger

strikers;

reaffirm adherence to professional ethical standards in military detention

settings by issuing policy and position statements, speaking out, and

providing professional and public education programs;

conduct fact-finding investigations regarding the involvement of physicians

and psychologists in incidents of torture and other forms of cruel, inhuman,

or degrading treatment of detainees in military detention settings;

take disciplinary action against members who have violated standards of

professional conduct;

support state legislation to strengthen the authority of licensing boards

to discipline health professionals who engage in torture.

The American Psychological Association should repudiate the report of its

Presidential Task Force on Psychological Ethics and National Security that

condones the participation of psychologists in interrogation and adopt ethical

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the Health Professions Scholarship Program, as well as to all medical

residents who will serve in the military.

Health professionals assigned to military detention centers should receive

direct, not online, pre-deployment training in the human rights of prisoners

and the ethical obligations of health professionals in these settings.

A special section on dual loyalty, including relevant ethical tensions and

means for addressing them, should be added to the specialty board exams

of physicians who will serve in the military.

F>> > '==>> K

alleging prisoner abuse and inform the complainant of the nature and scope

of its investigation, and (d) formally prosecute complaints of prisoner abuse

in hearings that afford the complainant opportunity to testify and call

witnesses. Disciplinary boards have the authority to subpoena evidence and

compel witnesses in cases involving prisoner abuse.

Judicial review of a disciplinary board decision to dismiss a complaint

involving prisoner abuse is available to a complainant.

Misconduct complaints based on prisoner abuse cannot be time-barred.

The DoD and CIA should cooperate with state licensing and disciplinary

boards in cases where detainee abuse is alleged. Congress should support the

state disciplinary process in cases involving abuse of detainees by mandating

cooperation by the DoD and CIA as well as providing financial resources to and

sharing relevant evidence with state disciplinary and licensing boards.

Finding 8. The militarys medical education programs and pre-deployment trainings lack

transparency and fail to provide military health professionals with the skills and ethical

grounding necessary to ensure that they protect the human rights of detainees. Curricula

on medical participation in torture do not reflect the requirements of law or ethics.

Recommendation: The DoD should reform education and training of military

health professionals to ensure compliance with professional ethical responsibilities

toward detainees. It should require that medical schools (including the Uniformed

Services University of the Health Sciences), military graduate education programs,

officer training schools, and military deployment training programs certify health

professionals knowledge of professional ethical principles regarding treatment

of detainees.

The U.S. military should provide ethics and human rights training formilitary physicians at its medical school, in basic officer training, and in

pre-deployment training. That training should include review of the role

of health professionals in preventing, documenting, and reporting human

rights abuses. It should also include review of relevant codes, opinions,

and policies of major medical organizations. The trainings should be as

transparent as possible.

Training in ethics and human rights applicable to military service should be

mandatory for medical students at civilian universities who participate in

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ethics abandoned - medical professionalism and detainee abuse in the war on terror

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